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End of Life Decisions – Do-Not-Resuscitate Research Paper

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Updated: Jun 26th, 2020

Introduction

Cardiopulmonary resuscitation (CPR) is a critical medical intervention that plays a role in prolonging death. According to Brindley (2013), it is the best intervention for saving the lives of patients with acute illnesses. Thus, it is important that the patients, healthcare professionals, and families be well informed on the role of CPR in saving lives. Moreover, resuscitation issues should be individualized because it is impossible to predict whether a patient will require CPR or not. Salins, Pai, Visyasagar, and Sobhana (2010) acknowledge that the decision concerning resuscitation after a cardiac arrest is determined by the orders of the patient, appraisal by the physician, and the probability that the CPR will be successful. In addition, the physicians must consider the futility of the intervention in cases where the probability of improving the quality of life is low.

Despite these guidelines, various legal and ethical issues affect do-not-resuscitate (DNR) orders. These issues must be taken into account before resuscitating a patient. Ethically, it is important that the patient’s autonomy and consent for a DNR order be respected. Accordingly, beneficence (effective decision-making) and non-maleficence (avoiding harm) must also be considered. Two major issues determine the legal aspects of DNR orders.

First, whether the orders of the patients with regard to DNR are documented and respected. Second, whether the physicians institute or withhold the DNR order based on the request of the patient. Yuen, Reid, and Fetters (2011) indicate that the family’s response with respect to the institution or withholding of DNR orders determines the legal course of action taken against healthcare professionals. Furthermore, the standards and the decision-making procedures of the patients are important. The aim of the current research is to assess the legal issues surrounding DNR orders. Specifically, the essay looks at patient advocate and guardianship limitation issues concerning DNR orders.

End of life decisions: Do not resuscitate

In reference to Bailey et al. (2012), DNR is a medical intervention procedure used to prolong death. Two situations determine the institution or withholding of end of life medical interventions. First, it is important to analyze the impact of withholding interventions in patients whose disease or illness can be improved through CPR. This promotes their quality of life. Second, the actions of the health professionals must be considered in case of a DNR order.

In this regard, there is the likelihood that legal issues may arise following end of life intervention procedures. Brindley (2013) reports that physicians should make sure that they engage patients early enough about their end of life care. This guarantees that the decisions regarding DNR orders are made in advance and promote the best wishes of the patients and their families. It also offers family members the opportunity to give their input with respect to the wishes of their loved ones in end of life care. However, Bailey et al. (2012) note that many physicians tend to delay the DNR decision-making process based on the assumption that there is a lot of time to discuss matters about death in the future. As a result, past research studies have reported that most DNR orders are made in the last days of life. Cherniack (2002) indicates that health care professionals are not very precise with prognostication, and thus, it is crucial that the end of life choices be made in advance.

Cherniack (2002) states that the number of DNR orders has been increasing drastically over the years. The majority of these orders are reported in the United States, and the analysis of mortality trends indicates that most patients die the following consent to a DNR order. The Patient Self-Determination Act of 1991 was created to deal with issues affecting patients with acute illnesses. It advocates for the privileges of the patients in relation to DNR orders and other end of life issues. The act recognizes the importance of incorporating patients in medical decision-making to ensure that they issue advanced directives concerning their end of life care.

According to Eliott and Olver (2010), DNR decisions should be based on the best interest of the patient. However, there have been disagreements in literature over who has the authority to make these decisions. While some authors argue that doctors should make DNR decisions, as they are well informed and educated on their implications, others note that respect for the patient’s decision is inevitable (Eliott & Olver, 2010). Despite such arguments, most researchers recognize the importance of involving patients in matters that affect their end of life care. Yuen et al. (2011) argue that advocating for the autonomy of the patient is the right goal of medicine. Thus, medical professionals should ensure that they advise the patients and their families on the role and the implication of DNR orders in advance. On the contrary, Salins et al. (2010) argue that it is not always easy for physicians to follow the requests of the patients concerning DNR orders as they view them as uncomfortable and against the mandates of the medical profession.

In addition to the respect of the patient’s autonomy, Yuen et al. (2011) indicate that physicians should ensure that the families are psychologically prepared. Moreover, the failure of doctors to provide accurate information on the implications of DNR orders is likely to provoke legal concerns. Bailey et al. (2012) note that comprehensive and accurate discussions between physicians, patients, and family members are important as they avoid legal issues that may arise if the patient’s orders are not followed. Additionally, Eliott and Olver (2010) report that the patients and their families should be well informed on the limitations of CPR and the effects of withholding the DNR order.

In reference to Biegler (2003), it is wrong for health care professionals to make unilateral decisions about the end of life care of their patients, whether they have end of life orders or not. Therefore, the wishes of the patients and the families should be taken into account, and the parties should reach a consensus in advance. Cherniack (2002) indicates that the law of the United States does not only recognize the importance of including patients and families in the decision-making process but also giving them accurate and unbiased information. Despite the opinions of the families and the physicians, the patient’s autonomy plays the greatest role in determining the course of action during resuscitation. Bailey et al. (2012) recognize that families may disagree with the DNR orders when the patient is critically ill and requires CPR. It is, therefore, vital that patients sign agreements on DNR orders, as this would assist in the resolution of conflicts.

Biegler (2003) acknowledges the importance of an informed consent process with respect to DNR orders. This process ensures respect for the autonomy of the patients and offers an assessment of the impact of instituting or withholding the DNR order. Despite the application of the informed consent procedures, Salins et al. (2010) state that some medical providers still argue that DNR is a medical decision rather than that of the patient. Other scholars tend to disagree on whether the will of the patient surpasses that of the physician. Nonetheless, as with all medical decisions, the autonomy of the patient is likely to dominate the DNR order. In addition, the interests of the guardians and the loved ones are unlikely to play a role in the administration of the DNR orders. In summary, legal issues in DNR can only be avoided through timely and comprehensive decision-making process that involves the physician, patients, and their families.

Conclusion

CPR is an end of life intervention that is used to treat cardiac arrest and prolong death (Eliott & Olver, 2010). The law affords patients the right to make end of life decisions such as DNR orders. However, many legal issues may affect the institution or withholding of the DNR orders. Moreover, researchers have argued that DNR orders should be a medical rather than a patient’s decision.

It is important that the patient’s wishes and autonomy be respected in DNR orders. Bailey et al. (2012) argue that the autonomy of the patients should come before the interests of the doctors and their families. In an effort to avoid legal issues that may result from DNR orders, a comprehensive decision-making process is important. The patients and their families should be well informed on the implications of the DNR orders. Furthermore, there should be an informed consent procedure, which should allow the patient to document their wishes beforehand. The consenting process also eliminates any family disagreements that may occur. In summary, DNR orders should focus more on advocating for the right of the patient than any other party.

References

Bailey, F. A., Allen, R. S., Williams, B. R., Goode, P. S., Granstaff, S., Redden, D. T., & Burgio, K. L. (2012). Do-Not-Resuscitate orders in the last days of life. Journal of Palliative Medicine, 15(7), 751-759.

Biegler, P. (2003). Should patient consent be required to write a DNR order? Journal of Medical Ethics, 29(11), 359-363.

Brindley, P. G. (2013). Perioperative do-not-resuscitate orders: it is time to talk. BMC Anesthesiology, 13(1), 1-3.

Cherniack, E. P. (2002). Increasing use of DNR orders in the elderly worldwide: whose choice is it? Global Ethics, 7(3), 303-307.

Eliott, J. A., & Olver, I. (2010). Dying cancer patients talk about physician and patient roles in DNR decision making. Health Expectations, 14(3), 147–158.

Salins, S. N., Pai, G. S., Visyasagar, M., & Sobhana, M. (2010). Ethics and medical legal aspects of “not for resuscitation”. Indian Journal of Palliative Care, 16(2), 66-69.

Yuen, J. K., Reid, M. C., & Fetters, M. D. (2011). Hospital do-not-resuscitate Orders: Why they have failed. Journal of Internal and General Medicine, 26(7), 791-797.

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